Reviving the Dream: Correcting Suboptimal Results from Injectable Treatments
When I'm in my office and consulting with patients, I often think of my favorite childhood story, The Rose Geranium, about a woman who received a beautiful flowering plant as a gift from a neighbor. After she placed the plant on her kitchen table, she was struck by how much nicer it would look if the table looked better. So she repainted the table. Of course, then the chairs didn't look so great, so she had to repaint them, too. Although the table and chairs looked wonderful, they really made the windows look shabby, but cleaning and some new curtains took care of that. And so on it went, until the woman's family came home to find the whole house transformed and freshly baked cookies waiting for them on the kitchen table.
Perhaps it was a harbinger of things to come that this quintessential makeover story so captured my imagination at an early age. Many of my patients' makeovers are jump-started by the first procedure, which is their rose geranium, and they occur one step at a time. I'm sure this is true of your patients, too. The advantage of step-by-step progress is that it gives patient and physician the opportunity to develop rapport and mutual understanding. However, progress grinds to a halt and the patient-physician relationship can become strained, if not fractured outright, when something goes wrong.
Over the past several years, I've seen a significant increase in the number of patients requesting correction of dermal filler and botulinum toxin treatments received prior to consulting with me. Some of these patients live around the corner from my offices, while some have traveled thousands of miles. Some are self-referred; others have been referred by the injectors who treated them originally. Invariably, all are experiencing a cocktail of conflicting and complex emotions. I find that the key to managing these patients successfully is to first acknowledge their distress; in many instances, this may be profound and accompanied by other emotions including guilt, shame, and anger. I typically spend a large part of the initial consultation simply listening to the patient's concerns and discussing how we can improve the situation rather than over-focusing on the previous bad experience. It is absolutely essential to document the patient's baseline through careful photography and note-taking before embarking on procedures to correct a previous suboptimal result. Some patients may need several consultation sessions before they are emotionally ready to proceed with corrective treatment. Others opt for treatment during the first visit, as in the case presented below.
ASHAMED TO SEEK CORRECTION
A 35-year-old white woman who was a government employee presented requesting correction of treatment with a non-particulate non-animal stabilized hyaluronic acid (NASHA) filler (Juvéderm®, Allergan) and botulinum toxin A (Botox®, Allergan) one month previously. She complained that the treatment had left bumps under her eyes and raised her eyebrows too high on her face so that she looked permanently surprised. She stated that she was too embarrassed and ashamed to return to the physician who had treated her. She reported smoking cigarettes occasionally.
On examination (Figure 1) the patient had Fitzpatrick type I skin. There was contour irregularity due to misplacement of the NASHA filler and focal bluish discoloration of her lower eyelids due to injection of the filler too superficially with consequent development of the Tyndall effect. The medial and middle one-thirds of both her eyebrows were elevated above the supraorbital ridges.
During consultation, the patient was tearful and expressed anxiety about the outcome of future treatments. It was recommended that she receive injections of small-particle NASHA (Restylane®, Medicis) and ovine hyaluronidase (Vitrase®, ISTA Pharmaceuticals) to correct the lower eyelid contour irregularity and Botox to re-shape her eyebrows. The patient declined Vitrase but agreed to treatment with Restylane and Botox on that day.
After topical anesthesia, 1cc of Restylane was injected with anterograde serial threading technique via a 30G needle into the deep dermis and subcutaneous tissue of each lower eyelid. Two injection points were used for each lower eyelid with medial and lateral fanning, performed by moving the needle to change its orientation within the skin during injection. Gentle medial-to-lateral massage and point pressure were applied to the lower eyelids after injection to achieve smooth contours.1
To re-shape the eyebrows, 4 units of a stock solution of 100 units of Botox diluted with 2.5cc preserved normal saline were injected into each of two points in the Frontalis muscle on the mid and upper forehead on the right side. This procedure was then repeated for the left side of the forehead. Periorbital rhytides were treated by injection of the Orbicularis muscles on each side with 12 units of Botox via three injection points within the orbital rim. For eye-opening, 2 units of Botox were injected subcutaneously into the pre-tarsal Orbicularis on each side, just below the ciliary margin in the mid-pupillary line, to bring down the lower eyelid rims by a fraction of a millimeter.2
At follow-up 12 days later, the patient reported that she was delighted with the results and that she no longer felt "like a freak." Examination revealed significant improvement in the lower eyelid contours and the position of the eyebrows. There was moderate improvement of the bluish discoloration of the lower eyelids. For further improvement, 0.8cc of Restylane was injected into the lower eyelids as described above. Additionally, 1.2cc of Restylane were injected into the patient's nasolabial folds.
During the third treatment session, three weeks after the initial treatment, 1cc of Restylane was injected subcutaneously into the lower eyelids, the supramedial midface, and just below the lateral one-third of the eyebrows. Anterograde serial threading was used as previously for the lower eyelids, while serial puncture with post-injection massage was used for the midface and below the eyebrows. Vitrase was recommended for correction of the residual lower eyelid contour irregularity and discoloration, which were most apparent when the patient half-closed her eyes.
The patient returned for Vitrase treatment seven weeks after the initial treatment session. Her lower eyelids were injected with Vitrase (200 USP units/ml) diluted 1:3 with 1% lidocaine with epinephrine: 0.1cc diluted Vitrase was injected intradermally at each of five points on the left lower eyelid and at each of four points on the right lower eyelid. Although the patient was advised to follow up two weeks after Vitrase treatment, she did not return for follow up until four months later—six months after the initial consultation and treatment. She expressed her profound appreciation of the treatment that had been performed and its positive impact upon her self-esteem. On examination, she had sustained improvement of lower eyelid contours, although the need for further botulinum toxin treatment was apparent.
DISCUSSION
This is both an exciting and a challenging time in which to be working with injectables. As FDA approval of new products draws closer, so too does the opportunity to further individualize and optimize treatment paradigms for our patients. Injectables such as Botox, Restylane and Juvéderm have been used safely for many years throughout the world and have gone through a stringent FDA approval process. The same is true of Reloxin, a botulinum toxin A used for years in Europe and elsewhere under the brand name, Dysport®, and now awaiting FDA approval. However, injectable safety has come under increased scrutiny of late, including a recent FDA safety hearing on dermal fillers.3 This is because of a relatively small number of adverse events resulting from inappropriate selection of injectables or the use of inappropriate injection techniques. An obvious example is the temporary paralysis suffered by a number of patients in November 2004 after they were injected in Florida with an unapproved botulinum toxin that was not intended for human use.4 Perhaps less obvious are the situations where an approved injectable is injected into an inappropriate area or with inappropriate technique. In the case discussed above, Juvéderm, an FDA-approved, nonparticulate NASHA, was misplaced and injected too superficially into the lower eyelids.
I believe that there are two aspects to injectable safety. The first aspect is to uphold the highest standards of patient care via thorough pre-procedural evaluation and fully informed consent- including the disclosure of off-label use of injectables, meticulous product inventory and procedural documentation, and consistent maintenance of the sterility and integrity of injectables. The second aspect is to select injectable products and to employ injection techniques that optimize patient safety. I prefer to use NASHA fillers for facial volume replacement because they are homogeneous, can be injected via small gauge needles with slow, controlled technique and can be reversed if required through the injection of hyaluronidase or through simple extrusion.2 This approach is borne out by the recent FDA safety hearing on dermal fillers, during which the independent advisory panel to the FDA specifically noted the well-established safety record of hyaluronic acid fillers. In order to optimize aesthetic outcomes and to prevent clinical sequelae from vascular occlusion, I am particularly selective about the fillers and injection techniques I choose for specific, anatomically unforgiving facial areas including the periorbital frame, the forehead, glabella, central midface, and lips. I generally use small particle NASHA (Restylane) with anterograde injection technique to minimize tissue trauma and the risk of inadvertent intravascular injection.
The strategy employed for correction of this patient's suboptimal results was to dissolve the misplaced NASHA filler with hyaluronidase and to replace it with appropriately placed NASHA. Botulinum toxin was employed to correct an aesthetically undesirable result from previous botulinum toxin treatment. When I am injecting a patient for the first time with a dermal filler, the injection sites and the level of filler placement are designed to maximize aesthetic improvement and to minimize tissue trauma and resultant bruising. For a patient such as this, who had suboptimal results from previous filler injection, there are dual objectives: correction and aesthetic improvement. The former objective overrides the latter and may dictate injection sites and filler placement that somewhat increase the risk of bruising. Although the patient was counseled regarding this prior to treatment, she had little or no bruising after each treatment session. It is of note that the small particle NASHA (Restylane) injected into this patient's lower eyelids had excellent longevity, as evinced by the significant retention of volume correction six months after the first treatment. I find that this is generally the case: Patients injected with particulate NASHA within the periorbital frame often require maintenance treatment only after 12 to 24 months.
Successful treatment of patients with dermal fillers and botulinum toxin requires meticulous attention to product selection and injection technique. This is even more true where corrective work is involved. It is equally important to establish a strong and supportive relationship with patients during consultation and to maintain it throughout what is usually a multi-session course of procedures. I feel that the closeness of the bonds that develop with patients whose first consultation is for prior treatment gone awry more than compensates for this extra time and emotional energy.
Patients view the prospect of having "work" done with a mixture of anticipation and apprehension- the hope of fantasy and the fear of reality. Their decision to proceed is based upon the expectation that reality will at least approach the fantasy to some extent. The Cuban-French author, Ana•s Nin, wrote that dreams are necessary to life. For patients, poor results represent the shattering of a dream and this may profoundly impair quality of life. As confidence and trust are restored through corrective treatment, I find that patients often move beyond addressing the immediate problem to further treatment for the purposes of enhancement alone—and, ultimately, to revival of the dream.
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